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Avalere Health CEO Dan Mendelson discusses election’s impact on health reform

Wednesday, 03 November 2010 20:37 |

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Dan Mendelson, president and CEO of health care business and policy advisory firm Avalere Health talks to me about how yesterday’s elections are likely to influence the course of health reform.

Key takeaways:

PPACA won’t be repealed but may be modified
Republicans will use the appropriation process to influence how regulations are written
President Obama faces a choice: make some compromises that appeal to the Republicans or take a hard, partisan line
Cost reduction and delivery system reform efforts will gain favor
Doctors are likely to have to keep coming back to lobby for temporary reprieves from automatic reimbursement cuts under Medicare

Tags: Podcast - Healthcare Blogs - Healthcare Marketing Blogs - are - health - and - the - will

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Malpractice defense: Left Ureter Kinked During Hysterectomy

Wednesday, 03 November 2010 18:23 |

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In addition to my consulting work and writing the Health Business Blog, I’m chairman of the board of Advanced Practice Strategies (APS), a medical risk management firm that provides litigation support for malpractice defense and an eLearning curriculum focused on enhancing patient safety.

To learn more contact: Timothy Croke, Director of Demonstrative Evidence Group. This e-mail address is being protected from spambots. You need JavaScript enabled to view it or 617-357-0553 ext. 6664.

Here’s the Advanced Practice Strategies case of the month.

Judgment for the Defense
Left Ureter Kinked During Hysterectomy

The plaintiff underwent a hysterectomy, followed by a Burch colposuspension (sutures placed under bladder for support to help control urinary incontinence). The hysterectomy was performed by an OBGYN physician with a urologist present to assist with the Burch procedure. Both procedures were completed without intraoperative complications, and the patient was moved to the recovery room. Postoperatively, a kink in the patient’s left ureter, caused by a suture placed during the hysterectomy procedure, was discovered. As soon as this became apparent, the OBGYN physician and the defendant urologist returned the patient to the operating room, where they dissected out and reimplanted the remaining, undamaged ureter into the bladder, thus allowing the system to function normally. The patient did not suffer any long-term complications.

PLAINTIFF’S CLAIM:

Originally both the OBGYN physician and the urologist were named in the case, but the OBGYN physician was later dismissed. The plaintiff believed the urologist, as a physician who specializes in surgeries involving the urinary system, was primarily responsible for safeguarding the integrity of the ureters. She argued that the urologist, while acting as assistant to the OBGYN physician during the hysterectomy procedure, should have dissected out the ureters to make sure they were clearly visible and out of harm’s way, thus preventing the errant suture from kinking the ureter.

DEFENSE’S ARGUMENT:

During a hysterectomy procedure, a ureteral dissection is not routinely performed unless concern arises about a potential or actual injury to a ureter. Dissection presents significant risk, since the ureters course under the peritoneum and through a highly vascularized region that can easily be injured, resulting in major bleeding. The defendant assisted with the hysterectomy procedure by holding retractors to expose the surgical site while the OBGYN physician placed sutures to close the vaginal cuff and control nearby bleeding; it was these sutures that led to the ureteral injury. The defendant argued that only by placing the sutures himself could he have been aware of their depth, since this determination depends on the operating surgeon’s feel during the procedure.

___________________________________________________________________

VISUAL STRATEGY:

Collaborating with the defendant and his attorney via web meetings, phone calls, and emails, APS created visual aids illustrating the surgical procedures and the defendant’s part in those procedures.

We began with an illustration of the normal anatomy of the arteries and veins of the female reproductive system to show the ureters’ path under the peritoneum and their relationship to the many blood vessels nearby.

The next diagram of a superior view of the female pelvis was used to orient the jury to the surgeon’s view of this anatomy during the procedure. The ureters were printed separately on a clear overlay, emphasizing that their course below the peritoneum was not visible during the surgery.

A view of the orientation of the surgical field and the surgical view of female pelvis were used to illustrate what was visible to the surgeons; the ureters were again printed separately on a clear overlay, indicating their invisibility during the course of the surgery.

The next two boards were key elements in the defense. The first showed the surgeon’s view during the hysterectomy and, specifically, the suturing of the vaginal cuff. The second illustrated the defendant’s view during the hysterectomy and suturing. These boards reinforced the defendant’s argument that, as the surgical assistant, he did not have a direct view from his position on the left side of the patient of the OBGYN physician suturing the vaginal cuff. This second board revealed quite strongly that the only person who could really know the depth of the sutures placed to control bleeding around the left side of the cuff was the surgeon who actually placed them.

Another board showed the suturing of the bleeders around the vaginal cuff.

The Burch colposuspension illustrated on another board allowed the jury to see the location of the defendant’s part of the operation, far from the site of the ureteral injury.

Two last boards illustrated the anatomy in a parasagittal view, both before and after the hysterectomy procedure. These views helped the defendant’s attorney to reinforce the close proximity of the vasculature to the ureter and that the ureter was hidden and not plainly visible to the urologist.

This series of illustrations helped the defense successfully convey the following key points to the jury:

The hysterectomy was done correctly and followed the standard of care.
The defendant urologist was not directly involved in suturing the vaginal cuff during the hysterectomy procedure; he only served as an assistant while the OBGYN physician performed the procedure.
Dissection of the ureters can pose significant risks because of their close proximity to the vasculature, and it is thus not performed during a hysterectomy unless necessary.
Although its occurrence in this case was unfortunate, the kinked ureter was recognized and corrected promptly and appropriately.

RESULT:

The jury found in favor of the defense.

“I wanted you to know your illustrations in this case were outstanding. The jury foreman said they were very helpful in understanding the issues.”

—Attorney, Doug Durfee , Saurbier & Siegan, P.C., St. Clair Shores, MI

Tags: Physicians - Healthcare Blogs - Healthcare Marketing Blogs - the - and - was - hysterectomy - during

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Old, female and headed for the ED? Bring someone along who can speak up for you

Tuesday, 02 November 2010 23:20 |

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I accompanied a patient to the emergency department the other day and was glad I did. There’s just too much going on for an ailing patient to process alone, and it’s important to have someone there to be a second set of ears and eyes, provide moral support, ask questions, and –when needed– perform a quality control role. (I was actually very impressed with the place we went and we didn’t have any serious problems on this visit.)

A HealthLeaders article (Half of Elderly Women Unnecessarily Catheterized in ED) about an American Journal of Infection Control study provided a reminder of the necessity of bringing along a companion who can speak up. From the article:

The report… raises questions about whether elderly women are being unnecessarily exposed to risk of infection, a known hazard of urinary catheterization.

The researchers examined 532 instances of catheter placement and found that 48.3%, or 58 of those patients who were female and age 80 or older did not have indications for catheter placement.

Overall, for both men and women regardless of age, about one sixth of ED patients had a UC placed without a clear reason. “Women were twice as likely as men to have a nonindicated UC placement,” they wrote. “About 40% if the patients had no documented physician’s order for placement.”

The authors acknowledge that the catheterization practice may reflect other factors that weren’t captured in their review, such as dementia, urinary incontinence and immobility, which may have been reasons for the catheter placement.

One reason –though not the only one– that patients like this are unnecessarily catheterized is for the convenience of the hospital staff. If the patient has someone there with them they can at least ask if the catheterization is appropriate.

I’m always wary of industries that set up or allow processes that are designed to increase the convenience of staff at the cost of the customer. The airline industry is an example. Flight attendants and pilots cut to the front of the security line. Sure, lines are a pain and staff need to get to the plane, but so do passengers.

Tags: Hospitals - Healthcare Blogs - Healthcare Marketing Blogs - the - and - that - for - have

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New Health Business Blog subscription options: Email, iTunes, Kindle

Tuesday, 02 November 2010 00:55 |

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I’ve just added a Subscribe section on the right hand column of the Health Business Blog:

The iTunes button lets you subscribe to my podcasts in iTunes while the RSS Podcast option is for those who prefer a different player
Subscribe by Email sends you one email containing any posts I’ve written the previous day. You can unsubscribe at any time
Subscribe with Kindle is for those who want to read the blog using Kindle

Let me know if you have any feedback.

Tags: Announcements - Healthcare Blogs - Healthcare Marketing Blogs - the - you - any - those - for

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Quest Diagnostics CMO Jon Cohen discusses new Gazelle mobile app (transcript)

Tuesday, 02 November 2010 00:44 |

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This is the transcript of my recent podcast interview with Quest Diagnostics CMO Jon Cohen, MD.

David Williams: This is David E. Williams, cofounder of MedPharma Partners and author of the Health Business Blog. I’m speaking today with Dr. Jon Cohen, Chief Medical Officer of Quest Diagnostics. Dr. Cohen thanks for being with me today.

Dr. Jon Cohen: Thank you.

Williams: Quest has a new Gazelle app. What can you tell me about it?

Cohen: Gazelle is an application for smartphones. Right now it’s for Blackberry and Apple iPhone; we’ll be adding Android relatively soon.

Gazelle empowers people to see, store and share their critical medical information and gives them a chance to take control of their health anytime and anywhere. With Gazelle you can manage your personal health data and issues around your health data.

It makes your vital personal information available anytime, anywhere you go. Gazelle also allows you to store and share your health care information with whomever you’d like. You could store your child’s immunization records; you could store your parents’ personal health record.

The big differentiator in our personal health record is that the laboratory data that you have at Quest Diagnostics automatically get directly put into your Blackberry or Apple iPhone. If your lab results are available at Quest Diagnostics they will be downloaded automatically into your Gazelle account onto your phone so you don’t have to reenter all that data.

Then of course you can share it. You can e-mail it. You can fax it. Instead of filling out the usual two or three pages on the clipboard in the physician’s office you could e-mail or fax the entire file beforehand. If your daughter is signing up for Brownies and they have forms that they need to fill out, you could use Gazelle to e-mail or fax the data without having to fill out the forms.

In essence it’s no more forms to fill out at the doctor’s office and access to all your family’s information at all times and in all places.

The other big use case is In Case of Emergency, or “ICE.” Gazelle allows first responders to quickly access your critical health information.

Williams: Tell me more about the emphasis on mobile. Has this functionality already been available on the desktop or is this all-new functionality?

Cohen: It’s all-new functionality. We built this for a mobile platform deliberately. There was a lot of discussion at the beginning about making sure we could also use it on a desktop, but we told the development team that this is not going to be for the desktop. We said to build it so that the user interface and the patient experience are totally based on a mobile platform.

The big issue here is the philosophical divide about where your medical information should lie. If you have your medical information with your internist or family practitioner you may then see an orthopedist, you may see a cardiologist, and every one of those physicians will have in the future an electronic medical record for you. The problem is those electronic medical records in most cases don’t communicate with each other. If, however, you own your personal health information, you then can take it wherever you want and give it to whomever you want.

The information that’s in a personal health record is the critical information that a physician needs when he sees you. This includes information about medications, allergies and important medical problems; it includes your doctors’ contact information. It’s a different paradigm. You own it, so you can transport it and decide who is going to get it. Strategically this is a big difference in what happens with people’s personal health records.

Williams: You mentioned that the personal health record owner can us email or fax to share information from Gazelle. Can you just talk about the mechanism for fax? Is it done through a fax server to the physician’s fax machine?

Cohen: The application provides a choice. You can provide an e-mail address and send the information securely or provide a fax number. In that case it will go through a fax server to be faxed to whomever you like.

Williams: As you mentioned, medication information is also important. Is there or will there be integration with the patient’s PBM or health plan to include prescription fill information automatically?

Cohen: Yes, we developed it with the ability to bring all your medication information into Gazelle. That functionality is available now, depending on who your PBM is and who the pharmacy is.

Let’s say you have elderly parents living in Florida or Arizona and you want to hold their personal health record. In case something happens to them or they see another physician, now you can send that information to them essentially instantaneously.

A lot of people carry their child’s immunization history stuck on a little piece of paper in their wallet. You don’t have to do that anymore. Now you have that information with you at any time. If you are ever in an emergency situation it’s available to you.

Williams: What happens when a new lab result is reported? What’s the typical process that people follow in a pre-Gazelle world and how would it work with Gazelle?

Cohen: We receive over one million requests per year to mail or fax people’s lab results to them directly. There is a huge desire to have your own information. So that’s what’s happened in the past.

The issue going forward is that in 33 states and Washington, DC we’re allowed to provide this information directly to patients. What most people don’t realize is that in the other states it’s against the law for us to provide patients directly with their information unless the physician releases it.

That’s another strategic issue going on across the country right now. It’s our belief it’s your data, you own it, you should make decisions about how to manage it.

If you believe in patient centricity, which is the hallmark of Quest Diagnostics, if you as a patient own your information hopefully you will then begin to act more aggressively on the information as it becomes more transparent to you.

We’re trying to move away from paternalistic relationships where all the information was not available to patients. We believe once you have your information you’ll begin to act on it. So if someone sees an abnormal lab value or if they see that their vitamin D levels are low, for instance, they’ll ask, ‘Why is it low? What do I need to do about this? How do I fix this? What do I need to talk to my physician about?’

We believe greater transparency around data will make patients own their data more and act on it more appropriately.

Williams: When the patient gets direct access to their data, does that mean once the physician has reviewed it or would it come to the patient directly without the physician necessarily releasing it?

Cohen: For blood and urine values we built in a 48-hour delay. In other words, when your result is available, that result will go to your physician. After 48 hours that result is available to you in the 33 states and DC where it is allowed. If your physician ordered the lab we’re going to give him the result and after 48 hours we’re going to give it directly to the patient.

Williams: So if the physician wants to step in that’s ample time to allow him or her to do it?

Cohen: We believe that’s certainly enough time for the physician to step in and inform you or not. Unfortunately there are a significant number of cases where patients don’t get the information they need. It depends on whom you read; somewhere between 7 percent and 15 percent of patients don’t receive notice of abnormal results. Once we provide the information to patients we feel it will be easier for them to act on it even if the physician hasn’t been in touch with them.

Williams: Has the number of states that allow the direct release of lab information been rising or falling?

Cohen: It’s been rising and there is a pretty big push to make it national. The issue is state law versus federal law and which takes precedence. But there has been an increase. More states are moving toward providing patients with their information.

Williams: Is the typical patient likely to get all of their lab results on this platform? How much is the market fractured between Quest and others and can non-Quest lab data be integrated into the results?

Cohen: That’s always an issue. Quest is the largest diagnostic company in the world but there are other laboratories and there are other hospital labs. We can only provide the Quest lab results now in Gazelle because of the way it’s built.

Gazelle is an open platform. We expect other types of health care information or health care apps will be able to use our platform to provide information. That might include the results of a radiology study or an electrocardiogram.

Williams: Have you reached out to third-party developers ahead of the release? Do you have an expectation about any specific third-party applications that will be built on this platform?

Cohen: Not yet. We’ve talked to a lot of different organizations. There is a huge interest, whether it’s a cardiology group –meaning EKG’s—; whether a radiology group for issues around radiology results; whether it’s pain management for patients to manage their pain better by providing their medications. If you think of all the different groups and entities and diseases, there are a lot of people who are interested in providing that information to a mobile platform.

Williams: What’s the business case for Quest in developing and promoting Gazelle?

Cohen: The bigger picture is patients’ interest in improving quality of care and increasing transparency. We believe it is a big differentiator for us in the marketplace because patients can have access to information that is automatically downloaded.

We are going to look at different business models and other ways that we can explore what makes sense financially. Right now our proposition for this is to provide it to patients, get them their labs and see what other application developers will launch onto the platform. It differentiates us in providing better patient care, more patient centricity and ownership of their data as consumerism rises.

Williams: I’ve been speaking today with Dr. Jon Cohen, the Chief Medical Officer of Quest Diagnostics. We’ve been talking about the new Gazelle mobile app. Dr. Cohen thanks very much.

Cohen: Thank you.

Tags: Patients - Healthcare Blogs - Healthcare Marketing Blogs - the - you - and - information - your

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Healthcare Marketing Blogs

Avalere Health CEO Dan Mendelson discusses election’s impact on health reform

Malpractice defense: Left Ureter Kinked During Hysterectomy

Old, female and headed for the ED? Bring someone along who can speak up for you

New Health Business Blog subscription options: Email, iTunes, Kindle

Quest Diagnostics CMO Jon Cohen discusses new Gazelle mobile app (transcript)

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